Typical day for a Home Health nurse...
Hi guys, I thought it would be nice to start an ongoing thread to just post/vent about your usual day. With a lot of entries, it can sort of serve to show nurses who are thinking about getting into Home Health what it is really like on the good days and the bad.
Not a bad day today... started back per diem today.
6 cases, all in the same township. Not my usual zip codes though, so I did waste some time and scheduled visits akimbo, instead of in a line like I usually try to do.
8:00am :6 pt's, one needed labs/medicare/had to drop off at nearby hospital, one needed a urine c+s/aetna/had to use quest lab...not local, but one in my neighborhood, so I'll take this on my way home. One prefill/and recert oasis, a discharge, a HHA sup, and one regular CP check. Did quick review, got all lab supplies, mapped a route, made my calls, route goes to hell b/c of this and that.
First lady, very sweet elderly woman, just d/c w pleural effusions sec to CHF. Also has bad COPD. I got her labs on first stick (w butterfly d/t horrendously fragile skin and bruising sec streroids), reveiwed her meds, VS stable, edema but no change. Off I go.
Can't drop labs yet b/c I have to first get to next home by 10:30 or no one can let me in. This guy is mildly retarded and we prefill his mediplanner weekly. Get there, he hasn't taken several evening doses of meds. I prefill meds, call in refills...snag..RPh tells me the insulin pen is backordered by manufacturer. We will have to prefill syringes, of course pt has no vials or syringes in home. Call endo and lv mssg re pls give pt Rx for vials and syringes d/t shortage. Check sugar (132) and VS, and off I go.
Stop and hospital drop labs, grab a sprite and pop tarts from the vending machine (thought I'd be in my own neck of the woods and could stop at my house for a bowl of cereal, starving now)
Next pt, had to get there before 1 or no one will let me in. This poor woman w MS is STILL on the commode since when I called at about 9:15! She is upset b/c her aide will leave at 1:00 and she hasn't had her BM. She doesn't want MOM or enema, since she will be alone and is afraid to risk having to lay in stool until eve aide comes, if they come. Usual bowel routine is q M-W-F, didn't go on Monday, but belly is nice and soft, + flatus, + BS. I advise her to try more fruit, and if no success repeat her suppos tomorrow. She does admit she didn't eat as much as usual on the weekend. Her aide said when she gave the sup this am, there was no stool felt in the rectum as far as she could reach. (Wow, this aide is a good one!!) Then I check her S-P tube site, looks clean, she was worried, Instructed her on S+S infection, got the UA/C+S from the S-P Tube, VS WNL, and off I go
Next, LOL who has CA, family doesn't want her to know. I get there, she looks good, hubby is cute, says "Boy, it's cold out there." We have a mini chat about yes how cold it is, only to have him do it again 3 more times!! (A tad forgetful I am picking up!) Dtr arrives midway into vs, says doc wants labs repeated later this week. Apparently she was on spirolactone bid, another doc inc it to qid, her K went off the scale, they dec the spiro back to bid, and K is high norm so he just wants one more set to be sure. Call the doc, confirm the order (Uh doc, we can't take orders from family members!) VS WNL, review all meds, advise we will be back thursday for labs. off I go
Next, funniest LOL, she answers door in a robe and damp hair, her HHA just left and she feels clean and great. But she is all upset b/c she can't get the calculator to figure right. She asks me to double check her, which I did, and we figured out what happened, and she felt better. She was quite euphoric and agreeable, , saying "Oh yeah, yeah, yeah, yeah, yeah!" I was starting to wonder if she was flaky, but she knew to call her dtr, how to balance her checkbook, and was taking her meds correctly. Then she pulls out five Rx dated 1-21-03, two are new meds, but prn types. I asked her why she didn't fill them yet, she says, My dtr has been sick. Having been just sick as a dog myself, I asked her what pharm she used, and for some reason she uses one in my neighborhood so I offered to drop it off, b/c I know they deliver. She is so relived, she gives me a big hug. Off I go
Last vs, still no real food and I am famished. The discharge. Cute LOL, very ambulatory, very sharp. Review s+s she needs to report for emergencies, meds actions, s/e, and VS stable, she will still have PT, so the discharge paperwork won't be so bad.
2:15pm. Back to my township, drop wee wee at quest labs, drop off Rx at the pharm, get to my house. Reheat leftover Chinese and get a huge glass of water. My bones are aching from being in and out of the cold so much.
Worked on paperwork until 4:45, finished time sheet. End of story. I'll take charts back in tomorrow since I am working. Tomorrow it is supposed to snow, which means a lot of people will call out sick. I was supposed to do 3 new admits, but will probably get stuck w seven revisits b/c we will have to triage for call-outs and snow.
Pretty routine kind of day today.
Anyone else want to share??Last edit by traumaRUs on May 30, '151Jan 28, '03 by sunnygirl272had an orientee with me today, so we had a light day....today was her first day out on the road,2nd day of orientation...
1st and last visit-same guy, quad with 3 stageIV pressure ulcers...bid dressing changes..etoh abuse...pleasant, friendly, amicable noncomplian client...he is deteriorating...going to wound care center this week..not holding out any hopes there..they have not been too impressive of late...
2nd and 3rd visits were in the same town as each other, about 20minutes from#1....
#2: LOL , last sn visit...continuing with pt...dialysis...pleasant..an infrequent frequent flier...bp meds were d/c's last week due to loooooow bp...stable now....
#3 LOL, 1ppd smoker, bipolar, new pacer....freq gi bleeds w/transfusions...in er a coupla days ago with abd pain..sent home with Rx for prilosec...cannot afford...told the pharmacist to give her 5 pills, all she could afford for now...(EPIC pending)..she told me she was saving the pills for when the painwas excruciating...discussed how med works...needs to take regularly,,call to pcp for diff more affordable med...the nurse there will call client and spouse back after they talk to her doc...discussed dietary mods...suggested chili not good idea for supper tonight....(i'm serious!!) after all said and done, she thanked me adn said i had done more for her and taught her more than anyone else had...
in between we were in the office,had to order supplies for my quad..and for a client who speaks limited english and whose SO id trached and understanding her is a acquired talent...also reviewed our paperwork with the orientee, as she will not be going on laptop for quite awhile...showed her around the building a bit..
tomorrow i have her with me in the pm..another light day, will be in the office most of the morning working on chart d/cs...
great idea, hoolie!!!:kiss0Jan 28, '03 by Hellllllo NurseVery interesting. I have never done HH.
HH nursing has always been a mystery to me.Thanks for opening a window to your day.4Jan 29, '03 by hoolahanThis was today.
Got to work late due to snow and traffic. 4 re-visits and a new admit. BUT the new pt was known to me, she used to be mine in the past, so that makes life easier. Don't have to explain how the medicare regs are, etc... She is a CHF freq flyer
First pt, young man w spina bifida in w/c, has a nasty wound on foot. Takes off sock, foot is blue, but that is his normal he says, brick cap refil, but no pulses palp. He talks incesssantly but is very nice, and I think I will never get out of there for the babbling.
Next, an interesting owman also has a foot wound w osteo. She has a PICC but has another agency doing her IVAB's, we are there for the wound. She is able to do her own drsg, we are monitoring and measuring weekly. I handed her the diet sheet put in the chart for the case manager and ask her to look it over while I get the supplies ready. She says "I recently lost a lot of weight. But I don't follow any diet, my diet is with Jesus." Okaaaaay...... She gives herself lantus insulin q pm, but does coverage during the day w regular. Nonnote on the chart about the regular insulin. I ask her how often she uses the regualr, she says no one ever told her how often she should do it, but she covers herself twice a day. She has non chart to tell her how much to take. (I'm thinking, don't tell me, it's prescribed by Jesus, right? LOL) Call to doc, office closed, will fax a note w my questions to the office. Hey she's been doing it this way for weeks, it certainly is not an emegency to page the doc at this point!
Those two visits were in the township, now I head to the city. The senior housing apt complex I am to vist has terrible parking. I usually get a metered space out front,and never have a problem finding a space, not today. AND the rest of the street is blocked w PSE&G (Elec co) trucks and firetrucks. I can't tell what's up, but cops blocked me from going any further and I could wiggle down and accross to the lot. Circle the block once, Not a place to park, I give up and decide to move on and come back.
Next visit is at city limits and borders my own township. Young man w MS, I know him from my prior VNA employment. Drastic decline in his functional status, very sad to see. He remembered me, and he and his very loving and supportive family were pleasant and talktative throughout my vs. It was a CP (cardiopulm) vs since he was s/p pneumonia. Gave him his copaxone inj since he won't let his sister give it in his abd, so the site can be rotated.
Decided to stop home, eat lunch and let dog go pee. I was there all of 20 minutes, then back to the city, finally find a spot to park 2 1/2 blocks away, walk in the sluch, and it is still snowing. Cute little Spanish lady. We manage to communicate, then I call her dtr to relay the teaching, and find out the reason her BP is up 190/82, IS b/c she likes "a lot of salt". Advised dtr re same, and s/sx of CVA to watch for, she promises to check on her mom later and instruct her about the salt. Called doc's office, closed for lunch, left a message for the service.
Last visit is my new admit. This senior bldg is 3 miles from my house. I have a nice visit with my former pt, and discover she is taking 3 anti-platelet agents, and has clots when she blows her nose ( all 3 were given in the hosp according to the d/c instructions) and has diarrhea sec cholchicine for a new onset gout which flared up prior to her d/c for CHF. Got primary, he deferred the ? about her meds to the cardiac doc, exc the cholchicine which of course he holds. Try the cardiac doc, office closed, another note to fax.
Headed hoome, got here just before the kids got home 2:45, did my notes, sent my faxes, and finished paperwork.
Total 30 miles. Much easier day since no labs to run around, but the snow made even close driving slow-going.
How bout you sun? Or anyone else??14Jan 29, '03 by LoriAnnRNI can't go into details about my daily routines, but I did home health for about 8 years and I really enjoyed it. It has it's negatives but remeber this: your worst day in home health is still 5 times better than your worst day in the hospital setting!0Jan 29, '03 by sunnygirl272orientee again this afternoon...2 visits alone this am,my quad and another am dressing change...who later called the office cuz nobody had been there today...yes, early alzheimers,...(sigh)
then caughtup onsome paperwork in the office...(yay!!) then we went out and saw a lol on the southern edge of our territory.. s/p cardcath, sp ami....new rales, call to md..NP called in atb..***...afebrile....no cough...faint rales lll...whatever..we'll revisit friday to reassess..( not on diuretic)
next: lom w/pneumonia...out one of the far eastern edges of our territory...doing well...very sweet....humming along with willie nelson on the radio during breath sounds...lol...windows of trailer coated with about 45 yrs of nicotine...states he is down to 6 cigs per day....(riiiiiiiigh... )
lastly: my quad...with buncha friends, all drinking already...but all very helpful adn happy...()
tomorrow, orientee with me in the am, i am off at noon cuz i hafta go see my GI.....1Feb 1, '03 by cescaHi!
It was very intresting and informative reading this thread.
I am in process of chaning from hospital to home care andI had just had interview with 2 home care agency.
Thank you!3Feb 4, '03 by hoolahanInteresting day....
I am per diem, and so I prefer to see new admits. I got my wish and thensome today. 3 admits, within5 miles of office and 2 miles of each other, and 3 miles from my house...nice!
9:30, arrive at first home. This is a twist, b/c I am admitting a husband and wife together. I have had a rare few of these before.
Hubby first, he is 93 yr old, a former plumber, which he tells me about repeatedly, so much so, that I seriously wonder if he has some dementia. He gets stuck on one idea, and just stays w it like a broken record. Ex, after doing my oasis, History, etc... and I did viatls. I want to examine his feet b/c he is diabetic. He has on these glofer-type shoes, w laces. Well, I get them off, pull of the KNEE socks, and his feet are skanky! LONG nails, callouses, no pulses, but good refill, thick hardened skin, etc.. I got the socks back on but the shoes! OMG Finally needed a show horn. Not to mention the laces were woven in an interesting fashion! It took me ten minutes to untangle them, aND RELACE THEM, THEN try to shove them back on his feet.
Bottom line, he is pretty good for his age and will not need SN for long at all....then we met....
The wife...Miss kookoo. Man! My first clue was the bright red overdone lipstick. I probably shouldn't say too much, it would be too easy to identify. She has a foley, so we will be stuck with her until her family burns out from her bizarre behavior and outs her in a nsg home, I give it 3 months! They can call it early Alzhiemer's if they want to, but can you say major personality disorder???
Left there, it was pouring rain and cold now, and went to my thrid admit. 33 yr old male w rectal abcess and a STD, you guess which one. He is now bed bound, but still very with the program. They pulled his PICC line before leaving the hosp, and now they have ordered labs to be drawn. Not sure why except he is anemic and had renal insuff, but no H&H ordered, only a metabolic profile. He needs PT, HHA 5 W9 and MSW referrals. So a LOT of paperwork for his case.
Another interesting twist, I was unable to confirm meds and orders as the docs are on strike in NJ! So it was like working on a weekend.
Got home by 1:30, did my paperwork, and took it back to the office by 4:30.
While dropping my charts for review w the manager, who went out w me last week to do an oasis w me, to check for validity of answers. She told me my answers matched hers 100%, and that I am the only nurse in the whole agency that has happened with. Yet my eval last week was 100% average. Not one noteworthy mention! Oh well. Good thing I enjoy my work, b/c there is very little thanks from management for a job well done.1Feb 10, '03 by sphinxFor an interesting twist, after 2 years in the field, the past month I've been learning an office job, and I can give ya a brief run down of my day. (I work with a team that covers 1/3 of our county, one OB nurse who does the whole county, and one of our peds nurse does the whole west side of the county)....Monday, come in and pull all the referrals out of the inbox (Friday eve, weekend, and openings for today). Had already printed some Friday, had a bunch more today. Print them all out, assign nurses to them on computer, check weekend log for when revisits are needed and leave copies of report in nurses mailboxes. Assign todays openings. Try and confirm everyone's schedules all at once, cuz everyone (mostly) wants to get going early. Check voice mails, one lpn calls out. One RN (our 2nd IV nurse) is in computer class this week. I actually manage to cover all the visits, even the IV visits, which I was worried about, as our team only has the 2 IV nurses plus one that is a weekend nurse who works 1-2 days a week 4 hours for us (not on today). I actually got my paperwork to the right people on time (secretary, MD, nurses), and scheduled BID visits for the week. Meanwhile took orders for MSW, PT, OT and HHA. Took MD orders over the phone and occasional questions from patients. Answered questions from nurses who call asking me stuff/advice. Surprised to find I even know things that a more experienced RN didn't know. People ask me for computer advice even. I put pt's on hold, go over recerts that need to be done and remind nurses....etc.....I've had some hairy days. We had 18 referrals in all, but most to be revisisted later in the week. Last week was horrid, way busy, way short staffed, all our nurses very upset about high caseloads, etc.Today was an easier day all around. Everyone was more relaxed, the nurses as well as me. And the boss had the day off.0Feb 15, '03 by Scavenger'sWifeGreat thread, Hoolihan.
I have worked Med-Surg for 4 years and 1-1/2 years with Hospice.
I just took a Home Health job and will start March 6. I will do some case-manager and some home visits. Altho I did home visits w Hospice, and had done a little cross-training w HH, this will be a real change for me. I am really looking forward to it. I have an ortho prob w my left ankle and really needed to get a job where I didn't pound the floors for 12-14 hours.
We are going all computer and have lap-tops for our paperwork in the field. Do you have experience w this? I am fairly computer-competent and have no fears of it.
The thing I have NO experience w is the insurance stuff. With my Med-surg backgraound, the nursing skills and documentation skills are what got me the job. How hard is it to grasp the insurance, OASIS, etc.???
Any input will be welcomed.0Feb 15, '03 by renerianCongrats on your new job. I loved home health. I would love to be up where Karen is and I would go work with her. Our agency was not very good to the nurses plus our service area was 7 counties. Way to big. Mostly rural and I spent a minimum of 20 to 25 hours per week just driving which I did not get paid anything for since I was per visit. I think if your employer pays you well you will love it!
renerian0Feb 15, '03 by hoolahanThanks for the diff perspective sphinx!
Here was yesterday & today, along w some venting.
Yesterday, get kids to school, arrive in office 8:30, get handed a chart and told pt needs a foley change, and HHA leaves at 9:30, so I have to leave NOW to get there on time. (Yes, I was pi$$ed!) I also have 2 news, and literally did not have time to call them to confirm. Now I will have to call them from the road, and if they don't work out (ie still in hosp, or pt has a MD appt or something else going on) I will have to play find more visits, which really sucks. The supervisors all greddily home in on you, trying to pawn off the worst visits possible. AND I hate getting visits in bad areas after 2pm. I plan my day so I am in the city in the am, and the burbs in the pm. This way the drug dealers are still alseep when I am in the city, and the drunks are still somewhat coherent before they start drinking, and the safer visist I leave to the afternoon.
So, I rush out to the first pt home, change the foley, do a HHA sup and all is well, I am done and out of the way of the HHA by 9:20, so she now has 10 min to get pt OOB for the day. Thing that irritates the heck out of me is a family mbr is sitting in the living room watching cartoons, couldn't even get his lazy arse up to answer the door. God bless the aides, some people really treat them like servants, and it bugs me!
Back to the car. Called my new admits, they are a go, thank goodness, and off I go, first vist in city, woman is a doozy. No she doesn't have a problem w etoh, she just parties too hard sometimes. She honestly tells me she went on a binge, and fell two times, second time she couldn't get up. She says, that is IT, I am not gonna drink non more...uh huh. What is your plan to not drink anymore. Oh I don't have no plan, I'm just not going to do it. What about if you get depressed, or stressed, how will how handle it, what will keep you from reaching for a drink? I just won't....uh huh.....Drink du jour 2 cans of beer (they must be the 32 oz cans) and a pint of ginger brandy. She prefers scotch but can't afford it. She needs help getting a new bed. She is HUGE, and can't get in and out of bed easily b/c she only has a mattress on the floor. Uh, we are not a furniture service...turf to MSW for referral. NO new RX in home, she can't find d/c instructions, can't find the rx, and one of the new ones is a "water pill" and she has +2 edema BLE...can you say readmit w CHF w/in a week?? LOL. Called the son, told him to get over on weekend, help her find RX and I am giving doc his number to f/u with. Call doc and explain, they will do what they can a f/u w call to son. I would love to say, listen, when you are serious about your health, and concerned enough to not lose your rx, call us, but until you are...adios!!
Next admit, elderly woman w compression fx in SEVERE intractable pain. Doc asked us out b/c he has no idea what to do w her. I suggest duragesic patch or oxycontin, he said he would call something in and let me know what it was. I like to give them a choice, so ultimately they make the decision. Nice woamn, nice family, but PT arrived in the middle of my admit and starts butting in, interrupting my questions. VERY irritating. Nice thing tho I did watch her physical eval, so that was helpful, did ask those questions on oasis, just observed her.
back to office to collect local new admits, in case of heavy snow. Got two, not too far, but in desolate areas = bad roads.
The one thing that irks the heck out of me, is our agency will do no triage of visits. They usa Saturday as an extra day to turf visits to. Case managers put pt they don't like to see themselves to the w/e schedule. and so many times in bad weather I risk my life to see someone who lives w multiple educated family mbrs, and I have to ask myself *****? Why waste our resources like this?? And in snow, forget it. Supervisors should call the pt's and see if visits are really needed. I did that when I was super. One Christmas I had it down to only two new admits who needed to be seen. Just irks me!!!!
Today, light snow, so I proceed to make my first vs, a sad woman w stg 4 lung ca, wants chemo and rad, AMA, they told her to go home and enjoy the rest of her life, she wants to fight. Will probably need o2 in near future. HHA placed.
Next vs, eldergy gent w early dementia, lives w wife, she can't do it all, I am thinking all they really want is a HHA. I am sending MSW to counsel for long-term planning, HHA, PT eval and PT eval need for the ordered OT which I do not think is necessary. He is slightly debilitated and had turp for bladder obs. I do educate the wife that if he eventually ended up w foley or SP tube, she could get hha ongoing. Hhhhmmm, food for thought. She gets my underlying drift and says, yes I will have to discuss whether he needs that w the urologist.
Back to the office, pick up two re-visits.
One bogus turf to w/e b/c it is in a BAD neighborhood, now it's afternoon too, but snow is keeping the creeps indoors I guess. This guy doesn't need a nurse today and really doesn't need one ever!! He will be d/c next vs I tell him.
Next vs, strange woman. She has more medically going on than on her chart diagnosis that is for sure, starting w moon face, and bulging eyes, but of course, a complete assessment was not done, and I can't get a sense of it from her meds. Despite her strange affect, she seems to have a good handle on her meds, and her diabetes. This little dingy apt had a fecal smell soooooo strong like sour sewage, I almost gagged when I walked in. her bathtub has water just pouring non-stop. She was trying to get a landlord to address it, but no luck. And probably won't have any luck. She is stable, weight is down, sugares are wnl, and I am on my way.
Hojme at 2:30, w mountain of paperwork, and here I am on the puter, so I will be doing it later. I just want a nap, but I refuse to lay down til it's done. I am procrastinating and I will pay for it later. While at office earlier, I picked up 3 new admit for tomorrow, and confirmed they are all home, so I will get charts ready and start a wee bit later tomorrow, first vs for between 9 & 9:30. Sounds like a winner, I always love it when there is no phone!2Mar 14, '03 by sunnygirl272thought i'd bump this thread...i'll chat about yesterday and today...
#1 & 6: a quad w/4 pressure ulcers (3 stage IV, one stage II) for bid dressings changes.
#2 an elderly gent in one of the ritzy senior living buildings, for dressing change to a nearly healed skin tear.
#3lovely lady who lives in a rather rustic cabin with her hubby...had to do pin care to her arm, Fx wrist, slipped on ice.
#4 another lovely lady, French-Canadian, speaks english, but i have been practicing my french with her also.. had a CABG, then had an abcess from the donor site in her thigh...we have her open for dressing changes...we are in there 2x/week... nearly entirely healed...d/c planned for next week...(personally think she coulda been d/c'd last week...)
#5 pia. young joint replacement. wants to become part of her armchair. no motivation at all.
#1  saw my quad again for BID dressign changes..
#2 gent with skin tear again..also yesterday adn today he showed me his photo albums...lots of OLD pix,...
#3gent w/ s/p hip replacement, assessed his healing stage II pressure ulcer on his nonsurgical side, no doubt partially shearage from pushing himself up in bed...wife doing well with his care...probably d/c next week...
#4 pleasant lady with s/p fem pop...doing well...general assessment, no wound care
#5 Hepc....call to md re: 10 pound weight gain in less than 24 hours..also new rhonchi since last nursing visit 2 days ago.
oh...and i forgot...yesterday i did a suture removal...on a boxer...(dog)..my quad's roommmate's dog had a mass removed, benign, but couldn't get back to see the vet...i had offered to take them out, he was gonna find a ride...couldn't..asked me yesterday if the offer was still open...he was a good boy...
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